What is the recommended treatment for a patient with a shoulder labral periosteal sleeve avulsion?

Shoulder Labral Periosteal Sleeve Avulsion Treatment

Arthroscopic surgical repair is the recommended treatment for anterior labral periosteal sleeve avulsion (ALPSA) lesions, as these injuries are associated with high recurrence rates and poor outcomes with conservative management alone. 1, 2, 3

Understanding ALPSA vs. Bankart Lesions

ALPSA lesions differ fundamentally from standard Bankart lesions because the anterior scapular periosteum remains intact, allowing the labrum and attached ligaments to displace medially and rotate inferiorly on the scapular neck rather than floating freely 3. This creates a nonanatomic, nonfunctional healing pattern that leads to recurrent instability even after the tissue heals 2, 3. ALPSA lesions are associated with worse outcomes than Bankart lesions and require distinct surgical techniques. 2

Diagnostic Workup

Initial Imaging

• Obtain standard radiographs with three views: anteroposterior in internal and external rotation plus axillary or scapula-Y view 4
• These identify associated bony injuries and rule out acute fractures 4

Advanced Imaging for Confirmation

• MR arthrography is the gold standard for diagnosing ALPSA lesions, particularly in patients under 35 years 1, 4
• The adduction internal rotation (ADIR) position during MR arthrography provides the highest sensitivity and specificity for ALPSA identification 2
• CT arthrography serves as an alternative if MRI is contraindicated 4

Surgical Technique Considerations

Arthroscopic Approach

• The anterosuperior portal provides optimal visualization for accurate identification of the ALPSA lesion 2
• The anteroinferior portal is preferred for surgical repair 2
• The critical surgical step involves converting the ALPSA lesion to a Bankart-type configuration by mobilizing the medially displaced labrum laterally to its anatomic footprint on the glenoid rim 3

Key Technical Points

• Distinguish the true labrum from dense reactive fibrous tissue that forms over chronic ALPSA lesions 2
• Reattach the labrum to the correct anatomic glenoid footprint, not to the medially healed position 2, 3
• A tensioned suture bridge technique between anchors may improve biological healing by maximizing the contact "footprint" between capsulolabral tissue and glenoid bone 5

Treatment Algorithm

Acute ALPSA Lesions (First-Time Dislocation)

• Proceed directly to arthroscopic repair rather than prolonged conservative management 3
• Early surgical intervention prevents the labrum from healing in a medially displaced, incompetent position 3
• One series demonstrated only 1 recurrence in 26 cases (4 acute, 22 chronic) with minimum 2-year follow-up using arthroscopic conversion and repair 3

Chronic ALPSA Lesions

• Arthroscopic repair remains the primary treatment 2, 3
• Assess for glenoid bone loss, which may require bone block or soft tissue augmentation procedures 2
• Higher failure rates in chronic ALPSA repairs compared to Bankart lesions indicate the need for meticulous surgical technique 2

Recurrent ALPSA Lesions

• Surgery is definitively indicated for recurrent labral tears causing symptomatic instability 1
• Conservative management has already failed in these cases 1

Critical Pitfalls to Avoid

• Do not apply rotator cuff treatment algorithms (including subacromial injections) to labral pathology—these are entirely different entities requiring different approaches 1
• Do not delay surgery in young, active patients with recurrent instability, as conservative management has demonstrably failed 1
• Do not accept medial healing of the labrum as adequate—this creates persistent instability despite tissue healing 2, 3
• Avoid inadequate mobilization of the labrum during repair, which results in nonanatomic reattachment 3

Role of Conservative Management

While initial labral tears may warrant a trial of physical therapy, activity modification, and anti-inflammatory medications 4, ALPSA lesions specifically have high recurrence rates and poor outcomes without surgical intervention 2, 3. The intact periosteum allows pathologic healing that perpetuates instability regardless of conservative treatment 3.